Diabetes

 A disease that results in too much sugar in the
blood (high blood glucose).
 Diabetes mellitus is a chronic disease caused
by inherited and/or acquired deficiency in
production of insulin by the pancreas, or by
the ineffectiveness of the insulin produced.
 Such a deficiency results in increased
concentrations of glucose in the blood, which
in turn damage many of the body's systems, in
particular the blood vessels and nerves.
7/23/2018Compiled by C Settley 2

 Type 1 diabetes (formerly known as insulin-
dependent) in which the pancreas fails to
produce the insulin which is essential for
survival.
 This form develops most frequently in
children and adolescents, but is being
increasingly noted later in life.

 The body’s immune system is responsible for
fighting off foreign invaders, like harmful
viruses and bacteria.
 In people with type 1 diabetes, the immune
system mistakes the body’s own healthy cells
for foreign invaders.
 The immune system attacks and destroys the
insulin-producing beta cells in the pancreas.
 After these beta cells are destroyed, the body
is unable to produce insulin.

 Type 2 diabetes (formerly named non-insulin-
dependent) which results from the body's
inability to respond properly to the action of
insulin produced by the pancreas.
 Type 2 diabetes is much more common and
accounts for around 90% of all diabetes cases
worldwide.
 It occurs most frequently in adults, but is
being noted increasingly in adolescents as
well.

 People with type 2 diabetes have insulin resistance.
The body still produces insulin, but it’s unable to use
it effectively.
 Researchers aren’t sure why some people become
insulin resistance and others don’t, but several
lifestyle factors may contribute, including excess
weight and inactivity.
 Other genetic and environmental factors may also
contribute.
 With type 2 diabetes, the pancreas will try to
compensate by producing more insulin.
 Because the body is unable to effectively use insulin,
glucose will accumulate in your bloodstream.

CHARACTERISTICS TYPE 1 TYPE 2
Insulin secretion Little or none Normal or excessive
Onset May occur at any age, but
usually under 30 years
Rapid onset
Any age, but usually over 35
years
Slow insidious onset
Incidence 10-20% of individuals with DM 80-90% of individuals with DM
Clinical manifestations Polyuria, polydipsia,
polyphagia, weight loss,
unexplained feelings of
weakness and fatigue,
hyperglycaemia, usually
underweight
May not have symptoms, or
have symptoms as Type 1.
may also have
asymptomatic complications
at the time of diagnosis,
usually overweight
Treatment Insulin
Diet
Exercise
Diet
Exercise
Oral drugs
Insulin

 Polyuria is usually the result of drinking excessive
amounts of fluids (polydipsia), particularly water and
fluids that contain caffeine or alcohol. It is also one of
the major signs of diabetes mellitus. When the kidneys
filter blood to make urine, they reabsorb all of the
sugar, returning it to the bloodstream.
 The most common cause of polyuria in both adults
and children is uncontrolled diabetes mellitus, which
causes osmotic diuresis, when glucose levels are so
high that glucose is excreted in the urine. Water
follows the glucose concentration passively, leading
to abnormally high urine output.

 Polydipsia is excessive thirst or excess
drinking.
 With diabetes, excess sugar (glucose)
builds up in the blood. If the kidneys
can't keep up, the excess sugar is
excreted into the urine, dragging along
fluids from the tissues.

 Polyphagia is excessive eating or appetite,
especially as a symptom of disease.
 In uncontrolled diabetes where blood
glucose levels remain abnormally high
(hyperglycemia), glucose from the blood
cannot enter the cells - due to either a lack
of insulin or insulin resistance - so the body
can't convert the food into energy. This lack
of energy causes an increase in hunger.

 A form of high blood sugar affecting pregnant
women.
 During pregnancy, the placenta makes
hormones that can lead to a build-up of glucose
in the blood. Usually, the pancreas can make
enough insulin to handle that. If not, the blood
sugar levels will rise and can cause gestational
diabetes

 Glycogenolysis and Gluconeogenesis
are two types of processes occurring in
the liver to release glucose into blood.
 Glycogenolysis, as name specifies is the
breakdown of glycogen to release
glucose molecules.
 Gluconeogenesis is the process which
results in the formation of glucose from
non-carbohydrate sources.

 Patients with diabetes often also have
diminished kidney capacity to excrete
potassium into urine.
 The combination of potassium shift out of
cells and diminished urine potassium
excretion causes hyperkalemia.
 Another cause of hyperkalemia is tissue
destruction, dying cells release
potassium into the blood circulation.

 The causes of hypokalemia in diabetics
include:
› (1) redistribution of potassium [K+] from the
extracellular to the intracellular fluid compartment
(shift hypokalemia due to insulin administration);
› (2) gastrointestinal loss of K+ due to malabsorption
syndromes (diabetic-induced motility disorders,
bacterial overgrowth, chronic diarrheal states); and
› (3) renal loss of K+ (due to osmotic diuresis and/or
coexistent hypomagnesemia).
› Hypomagnesemia can cause hypokalemia possibly
because a low intracellular magnesium [Mg2+]
concentration activates the renal outer medullary K+
channel to secrete more K+

 Blood glucose levels
› Normal levels- 4-6 mmol/l
 Fasting blood glucose
› >8 mmol/l found on two occasions indicates glucose intolerance
 Random plasma levels
› >11,1 mmol/l on more than one occasion is diagnostic of DM
 Oral glucose tolerance test
› Following the taking of a fasting blood glucose, the patient is
asked to drink a concentrated glucose solution. HGT is then
taken at half hourly intervals to determine how quickly the
glucose is removed from the circulation. The WHO recommends
that a glucose load containing 125g of glucose dissolved in
water be administered to the patient. A two –hour postprandial
plasma glucose of more than 11 mmol/l indicates DM.

 AIMS:
› Normalisation of insulin activity and blood
glucose levels
› Prevention of vascular and neuropathic
complications of DM
› Pillars of management are diet, medication,
monitoring and education

 Eat less
› Trans fats from partially hydrogenated or
deep-fried foods
› Packaged and fast foods, especially those
high in sugar, baked goods, sweets, chips,
desserts
› White bread, sugary cereals, refined pastas
or rice
› Processed meat and red meat
› Low-fat products that have replaced fat with
added sugar, such as fat-free yogurt

 Eat more
› Healthy fats from nuts, olive oil, fish oils, flax
seeds, or avocados
› Fruits and vegetables—ideally fresh, the
more colourful the better; whole fruit rather
than juices
› High-fiber cereals and breads made from
whole grains
› Fish and shellfish, organic chicken or turkey
› High-quality protein such as eggs, beans,
low-fat dairy, and unsweetened yogurt

 Lower blood pressure
 Better control of weight
 Increased level of good cholesterol
 Leaner, stronger muscles
 Stronger bones
 More energy
 Improved mood
 Better sleep
 Stress management
› Contraindicated when patient is hyperglycaemic
and has ketosis

ShorttermcomplicationsLongtermcomplications
 Hypoglycaemia
 Hyperglycaemia
 DKA
 Macrovascular
 Microvascular
 Diabetic foot

 Low blood sugar, the body's main source
of energy.
 Below 2,1-3,3 mmol/l

 Below 4 mmol/L Hgt
 Sweating
 Fatigue
 Feeling dizzy
 Being pale
 Feeling weak
 Feeling hungry
 A higher heart rate than usual
 Blurred vision
 Confusion
 Convulsions
 Loss of consciousness
 And in extreme cases, coma
 Headache

 Factors linked to a greater risk of
hypoglycaemia include:
› Too high a dose of medication
› Delayed meals
› Exercise
› Alcohol
› Abdominal surgery
› Tumours of the pancreas
› Liver disease
› Disorders of the pituitary gland and drenal cortex
› Drug addiction

 Classified as fasting or reactive
hypoglycaemia
 Fasting: occurs as a result of excessive
insulin production, decreased glucose
production by the liver, hormone
deficiencies, tumours of the cells of the
pancreas and auto-immune diseases.
 It is associated with CNS symptoms,
which are mental confusion, seizures and
coma.

 Classified as fasting or reactive
hypoglycaemia
 Reactive: occurs in the non fasting state,
which is about 3-5 hours after meals.
 Caused by a delay in insulin secretion or a
rising postprandial glucose level due to
rapid gastric emptying.
 The pancreas is unable to keep up with
rising levels of postprandial glucose.
 The result is delayed insulin hyper secretion
and hypoglycaemia.

 MILD
› The drop in glucose in the blood stimulates
the sympathetic nervous system, resulting in
a surge in adrenaline.
› Symptoms are: anxiety, irritability,
palpitations, diaphoresis (excessive
sweating), tremors and hunger.

 MODERATE
› Results in impaired function of the central
nervous system causing poor concentration,
headache, confusion, numbness of the lips,
slurred speech, double vision & drowsiness.

 SEVERE
› Impairs the central nervous system to the
extent that the patient needs assistance.
› Manifestations are disorientation and
decreased level of consciousness and
difficulty arousing from sleep, progressing to
complete loss of consciousness & seizures.

 Treatment:
› Oral administration of a fast acting sugar
› Fruit juice
› Sweets
› Sugar or honey
› Monitor symptoms
› Protein snacks
› Glucagon SC/IM if patient is unconscious
› 43% dextrose IV

 Nursing goals
› Within 20 min the patient should be alert and
be orientated to time, place & person
› Be fee of seizures
› Normal HGT levels
› Be knowledgeable about hypoglycaemia
before discharge

 Nursing interventions
› Administer fast acting glucose orally or
› SC/IV IM
› Monitor every 30-60 min
› When patient is awake, obtain history of food intake
and meds
› Review medication
› Monitor symptoms
› Nurse with side rails up
› Notify doctor when seizures occur
› Do not leave patient unattended
› Assess patient knowledge
› Evaluate diet and possible causes
› Health education

 Essential health information
› Patient should be informed about the condition
› Patient should carry a hypokit containing 1mg
glucagon to treat hypoglycaemia if it occurs
› Patient should be able to self test
› Medic bracelet
› Discourage patient from eating high calorie and
high fat food as it slows down the absorption of
glucose
› Healthy eating
› Compliance
› Exercise
› Between meal and bedtime snacks

 Hyperglycemia is a condition in which an
excessive amount of glucose circulates
in the blood plasma.

 Causes
› Not using enough insulin or oral diabetes
medication.
› Not injecting insulin properly or using expired
insulin.
› Not following a diabetes eating plan.
› Being inactive.
› Having an illness or infection.
› Using certain medications, such as steroids.

› Diagnosis:
 HGT > 35 mmol/l
 Urea and electrolytes may reveal elevated
sodium, decreased levels of potassium,
chloride, phosphorus and magnesium
 Serum osmolality of 343 mOsmo/l or higher
 Signs of severe dehydration

 Management
› Normal saline or 0,45% saline IV, at a rate of 200-
300 mmol/l until HGT levels drop to 15 mmol/l
› Fluid administration is given to correct
hypovolaemia and hypotension for the first two
hours of infusion, and dextrose solution are given
when the blood glucose reaches <15 mmol/l
› BP and Central Venous Pressure should be
monitored to assess the patient’s response to
rapid fluid infusion
› Cardiac monitoring
› Rapid acting insulin can be given as continuous
infusion to treat hyperglycaemia

 Nursing interventions
› Fluid administration as prescribed
› Monitor intake & output
› Provide nursing care of the patient in a
coma, if it applies

 Diabetic ketoacidosis is a serious complication of
diabetes that occurs when the body produces
high levels of blood acids called ketones.
 The condition develops when the body can't
produce enough insulin.

 Causes
› An illness (DM)
› An infection or other illness can cause your
body to produce higher levels of certain
hormones, such as adrenaline or cortisol.
› Unfortunately, these hormones counter the
effect of insulin — sometimes triggering an
episode of diabetic ketoacidosis

 Clinical features :
 Pain areas: in the abdomen
 Whole body: dehydration, excessive thirst, fatigue,
loss of appetite, or malaise
 Gastrointestinal: nausea or vomiting
 Mouth: dryness or fruity-scented breath
 Respiratory: rapid breathing or shortness of breath
 Urinary: excessive urination or frequent urination
 Also common: blurred vision, mental confusion,
sleepiness, weakness, or weight loss
 Hyperglycaemia
 Dehydration
 Acidosis

 Management
 To correct hyperglycaemia, dehydration &
acidosis
 Normal saline or 0,45% saline with
alternating dextrose to counteract rebound
hypoglycaemia
 Careful monitoring of electrolytes
 Rapid acting insulin IV
 Sodium bicarbonate may be given to
manage acidosis as it neutralises acid
 Treat underlying cause

 Nursing management
› Administer fluid as prescribed
› Vital signs
› Monitor signs of fluid overload
› Assess patient knowledge
› Health education

 Macrovascular disease is a disease of
any large (macro) blood vessels in the
body. It is a disease of the large blood
vessels, including the coronary arteries,
the aorta, and the sizable arteries in the
brain and in the limbs.
› Cardio vascular diseases
› HPT
› PVD
› Infection

 Small vessel disease
› Retinopathy (eye)
› Nephropathy (Nephropathy is a broad
medical term used to denote disease or
damage of the kidney, which can
eventually result in kidney failure)

 Weakness, numbness and pain from
nerve damage, usually in the hands and
feet.
 Autonomic &sensory

 Presence of several characteristic
diabetic foot pathologies such as
infection, diabetic foot ulcer and
neuropathic osteoarthropathy is called
diabetic foot syndrome.
 Due to the peripheral nerve dysfunction
associated with diabetes (diabetic
neuropathy), patients have a reduced
ability to feel pain.

 People with diabetes are more
susceptible to developing infections, as
high blood sugar levels can weaken the
patient's immune system defences.
 In addition, some diabetes-related
health issues, such as nerve damage
and reduced blood flow to the
extremities, increase the body's
vulnerability to infection.

 Inspect your feet daily. Check for cuts, blisters, redness, swelling or nail problems. Use a magnifying
hand mirror to look at the bottom of your feet. Call your doctor if you notice anything.
 Bathe feet in lukewarm, never hot, water. Keep your feet clean by washing them daily. Use only
lukewarm water—the temperature you would use on a newborn baby.
 Be gentle when bathing your feet. Wash them using a soft washcloth or sponge. Dry by blotting or
patting and carefully dry between the toes.
 Moisturize your feet but not between your toes. Use a moisturizer daily to keep dry skin from itching or
cracking. But don't moisturize between the toes—that could encourage a fungal infection.
 Cut nails carefully. Cut them straight across and file the edges. Don’t cut nails too short, as this could
lead to ingrown toenails. If you have concerns about your nails, consult your doctor.
 Never treat corns or calluses yourself. No “bathroom surgery” or medicated pads. Visit your doctor for
appropriate treatment.
 Wear clean, dry socks. Change them daily.
 Consider socks made specifically for patients living with diabetes. These socks have extra cushioning,
do not have elastic tops, are higher than the ankle and are made from fibers that wick moisture away
from the skin.

 Wear socks to bed. If your feet get cold at night, wear socks. Never use a heating pad
or a hot water bottle.
 Shake out your shoes and feel the inside before wearing. Remember, your feet may not
be able to feel a pebble or other foreign object, so always inspect your shoes before
putting them on.
 Keep your feet warm and dry. Don’t let your feet get wet in snow or rain. Wear warm
socks and shoes in winter.
 Consider using an antiperspirant on the soles of your feet. This is helpful if you have
excessive sweating of the feet.
 Never walk barefoot. Not even at home! Always wear shoes or slippers. You could step
on something and get a scratch or cut.
 Take care of your diabetes. Keep your blood sugar levels under control.
 Do not smoke. Smoking restricts blood flow in your feet.
 Get periodic foot exams. Seeing your foot and ankle surgeon on a regular basis can
help prevent the foot complications of diabetes.

 http://guidelines.diabetes.ca/bloodgluc
oselowering/casestudy1

 https://www.foothealthfacts.org/conditi
ons/diabetic-foot-care-guidelines

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